ASSESSMENT SUBJECTIVE:

DIAGNOSIS Imbalanced nutrition less than body requirements r/t inability to absorb nutrients because of biological factors secondary to cancer

PLANNING After 8 hours of nursing intervention the patient will demonstrate behaviours, lifestyle, changes to regain and or maintain appropriate weight

INTERVENTION - monitor vital signs - identified clients at risk for malnutrition - assessed weight, age, body build, strength, activity/ rest level, and so forth

RATIONALE - for significant changes - Provides comparative baseline

EVALUATION After 8 hours of nursing intervention does the patient demonstrated behaviours, lifestyle, changes to regain and or maintain appropriate weight? ___yes ___no Goal was met___ Partially met___ Not met___

OBJECTIVE: - Easy fatigue ability - Poor muscle tone - Initial body weight is 60 kg then drops off to 45 kg.

- note total daily intake - To reveal changes that should be made in clients dietary intake - measure/ calculate subcutaneous fat and - To establish muscle mass via baseline triceps skin fold and parameters midarm muscle circumferences or other anthropometric measurements - provide diet modification as indicated; mechanical soft or blenderized tube feedings - avoid foods that cause intolerances/ increase gastric motility - limit fiber/ bulk if indicated - It may lead to - consult with early satiety dietician/ nutritional support team as - For long term necessary needs

Why?

ASSESSMENT OBJECTIVES: - Damaged tissue in integumenta ry due to surgical incision

DIAGNOSIS Impaired tissue integrity r/t surgery

PLANNING

INTERVENTION

RATIONALE

EVALUATION After 6 hours of nursing intervention does the patient displayed progressive improvement in wound healing?

After 6 hours of - Noted poor health nursing practices such as intervention poor nutrition and patient will display lack of cleanliness progressive - Observe for other improvement in distinguishing wound healing characteristics of inflamed tissue - Inspect lesions daily for changes - Promote good nutrition with adequate protein and calorie intake and vitamin/mineral as indicated - Promote early mobility. Provide position changes, active/ passive and assistive exercises -maintain aseptic technique for cleansing/ dressing/ medicating lessions

- Promotes timely intervention of plan of care

- To healing

___yes facilitate ___no Goal was met___ Partially met___ Not met___

- To promote Why? circulation prevent excessive tissue pressure - Reduces risk of crosscontamination

ASSESSMENT SUBJECTIVE: sumasakit yung sugat ko kapag gumagalaw as verbalized by the patient OBJECTIVE: - Teary eyes - Facial grimace - Moaning when turning position

DIAGNOSIS acute pain r/t surgical incision

PLANNNING After 5 hours of nursing intervention the patient will verbalize methods that provide relief

INTERVENTION

RATIONALE

EVALUATION After 5 hours of nursing intervention does the patient verbalize methods that provide relief? ___yes ____no Goal was met___ Partially met___ Not met___

- Monitor vital signs - for significant changes - Perform a comprehensive assessment of pain to include location, characteristics, onset/ duration, frequency, quality, severity and precipitating factors - Determine possible pathophysiologic/ psychologic causes of pain - as this can - Note location of influence the surgical amount of procedures postoperative pain experienced -note clients locus of control - individuals with external locus of control may take little or no responsibility for pain management - to rule out worsening of underlying condition/ development of complication - to provide non

Why?

- perform pain assessment each time pain occurs. Note and investigate

changes from previous reports - provide comfort measures

pharmacologic pain management

- encourage use of relaxation techniques such as deep breathing exercise - administer analgesic as ordered

ASSESSMENT SUBJECTIVE: gagaling pa ba ako as verbalized by the patient OBJECTIVE: - not looking on his stoma - behaviours of avoidance

DIAGNOSIS Disturbed body image r/t surgery

PLANNING After 8 hours of nursing intervention the patient will be able to verbalize acceptance of self in situation, relief of anxiety and adaptation to altered body image and will be able to verbalize understanding of body changes

INTERVENTION -encourage family interaction with each other and with rehabilitation team

RATIONALE -acceptance of this feeling as a normal response to what has occurred facilities resolution. It is not helpful of possible to push patient ready to deal with situation. Denial maybe prolonged and be an adaptive mechanism because patient is not ready to cope with personal problems -enhance trust and rapport between patient and nurse

EVALUATION After 8 hours of nursing intervention does the patient be able to verbalize acceptance of self in situation, relief of anxiety and adaptation to altered body image and be able to verbalize understanding of body changes? ___yes ___no Goal was met___ Partially met___ Not met___

-provide support group for patient. Give information about how so can be helpful to patient -acknowledge and accept expression of feelings of frustration, grief, hostility. Note withdrawn behaviour and use of denial -provide hope within parameters of individual situation, do not give false reassurance

-words of encouragement can support development of positive coping behaviours

Why?

-promotes ventilation of feelings and allow for more helpful responses to patient

-encourage patient to look at/ touch affected body part

-to begin to incorporate changes in body image